Table 2. Chronic care model.

Essential elements of a health care system that encourage high-quality chronic disease care. The 2 elements implied but “missing” from the 4 principles of family medicine are the centrality of the patient journey, including self-management (blue shading), and the role of family medicine in multiple health systems models (green shading).

Self-management support

Empower and prepare patients to manage their health care. Patients are encouraged to set goals, identify barriers and challenges, and monitor their own conditions. A variety of tools and resources provide visual reminders. Emphasize to patients their role in managing their health. Use effective self-management support strategies that include assessment, goal setting, action planning, problem solving, and follow-up. Organize internal and community resources to provide ongoing self-management support to patients (eg, patient interest groups).

Community involvement

Mobilize community resources to meet needs of patients: community resources, from school to government, non-profit to self-help organizations. Bolster health systems’ efforts to keep chronically ill patients supported, involved, and active.

Health systems

Create an organization that provides safe, high-quality care. A health system’s business plan reflects its commitment to apply the chronic care model across the organization. Clinician leaders are visible, dedicated members of the team. Visibly support improvement at all levels of the organization, beginning with the senior leader. Encourage open and systematic handling of errors and quality problems.

Delivery system design

Assure effective, efficient care and self-management support. Regular and proactive planned visits that incorporate patient goals help individuals maintain optimal health and allow health systems to better manage their resources. Visits often employ the skills of several team members. Define roles and distribute tasks among team members of planned interactions to support evidence-based care. Provide clinical case-management services for complex patients with regular follow-up by the care team. Give care that patients understand and that agrees with their cultural backgrounds.

Decision support

Promote care consistent with scientific data and patient preferences. Clinicians have convenient access to latest evidence-based guidelines for care of chronic conditions. Continual educational outreach reinforces utilization of standards. Embed evidence-based guidelines into daily clinical practice. Share evidence-based guidelines and information with patients to encourage their participation. Integrate consultant expertise and primary care.

Clinical information systems

Organize data to facilitate efficient and effective care. An inclusive list (registry) of patients with a given chronic disease provides the information necessary to monitor patient health status and reduce complications with timely reminders for providers and patients. Identify relevant subpopulations for proactive care. Facilitate individual patient-care planning. Share information with patients and providers to coordinate care. Monitor performance of practice team and care system. For more information on the chronic care model, go to http://www.improvingchroniccare.org/.

Adapted from Wagner et al.⁷